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Communication 2

Communication 2. Assessing and Communicating Goals of Care Module 2. CPR: a lottery of sorts. At its best “… a gift of life: chest compression, ventilation, intravenous medication and defibrillation followed by years of productive and fulfilled being” At its worst

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Communication 2

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  1. Communication 2 Assessing and Communicating Goals of Care Module 2

  2. CPR: a lottery of sorts • At its best • “… a gift of life: chest compression, ventilation, intravenous medication and defibrillation followed by years of productive and fulfilled being” • At its worst • “… a scenario of vomit, blood and urine, then a confused brain damaged twilight, breathlessness from a failing ventricle, pain from rib fractures, until expiring in thrall to the full panoply of the intensive care unit or forgotten in the long darkness of the persistent vegetative state.” Saunders 2001

  3. Origins of CPR • CPR was first described by Kouwenhaven and colleagues in 1960 • For “…victims of acute insult - drowning, electric shock, untoward effect of drugs, anesthetic accident, heart block, acute myocardial infarction or surgery” • Developed for sudden unexpected death • Very different population from the majority who receive it currently Kouwenhaven et al 1960

  4. ‘Real-life’ success rates • Data from retrospective analysis • Survival to discharge up to 0-20% • Do not assess or describe morbidity of survivors (often very significant) • Huge variance according to patient selection Perbedy et al. 2003; Gwinnutt et al. 2000; Thorns & Ellingworth 1991; Smith et al. 2007

  5. Those who do well • Younger age • Cardiac aetiology • Ventricular fibrillation • Short duration • On a cardiac monitor Faber- Langendoen K 1991; Thorns & Ellershaw 1999; Weil 2005; Smith et al 2007

  6. Those who do poorly“almost no chance of success” • Pneumonia • Poor functional state • Requiring institutional care prior • 0% survival to discharge • Cancer • 0% in a study of 1268 CPR attempts • Renal failure • Hypotension • Older age Faber-Langendoen K 1991; Thorns & Ellershaw 1999; Smith et al 2007; Elshove-Bolk 2007; Skrifvars 2007

  7. What is a successful outcome? • Would all agree it is much more than simply ‘return of spontaneous circulation’ ROSC • Need to consider: • Morbidity • Survival to discharge from ICU, hospital • Place of discharge • Return to usual activities, employment • Quality of life Miranda 1994

  8. Compare this with the ‘reality’ of television • A 1996 study of 97 episodes of ER, Chicago Hope,and Rescue 911 in which CPR was depicted • 75 percent survived in the short term • 67 percent surviving in the long term • Lay press, community misconceptions (and those of health professionals) hardly surprising • Even seriously ill hospitalised patients have little knowledge about CPR and overestimate its success Diem et al. 1996; Heyland et al 2006

  9. “We need to acknowledge the inevitability of death to have some choice in the manner of our dying” Ashby et al. 2005

  10. Patient Preferences • Doctor understood patient preferences: • 86% who wanted CPR • 46% who did not want CPR • Doctors high estimation of QOL, higher prediction of 6 month survival and younger age correlated with : • higher likelihood of wanting CPR • higher likelihood of misunderstanding wish to forgo CPR The SUPPORT Principal Investigators 1995

  11. Patient Preferences • Communication about EOLC preferences, even in the seriously ill are uncommon • Polls frequently demonstrate widespread public pragmatism about death and dying • “I would never want to be a vegetable” • “When my time comes I do not want to be kept alive artificially” • But often such discussions are met with disbelief or hostility • Potential reasons for the difference? • polls vs. personal (real) situations Ashby et al. 2005; Hoffman et al. 1996; Sonnenblick et al. 1993

  12. More from SUPPORT • Longer relationship with doctor and having discussed resuscitation: • higher likelihood of understanding wanting to forgo CPR • Increase in NFR’s in the last month of life • > 75% in some cases • Of those 1288 patients who did not tell doctor CPR preferences during admission: • 30% told doctor in next 2 months • 50% of those who wanted to forgo CPR did not communicate this to their doctor • Declining QOL was not a prompt for discussion • The SUPPORT Principal Investigators 1995

  13. Useful Definitions • NFR • Not for resuscitation order • Does not specify goals of care or specify other management (does not equal palliative care) • Medical Power of Attorney (mPOA) • Appointed to make health decisions on a person’s behalf (should they lose capacity to do so) • Allows refusal of treatments (but cannot insist on futile treatments) • In the absence of a mPOA we in practice acknowledge the authority of the next of kin in informing medical decision making

  14. More Useful Definitions • Refusal of Medical Treatment Act (Vic) • Can be executed by a competent patient (or their MPOA) and relates to a current/existing condition illness • Specifically excludes palliative care • Advance Directive • Statement (oral or written) outlining wishes for future health and personal care • Complex and emerging area, validity a significant issue If you have ANY doubts, contact your hospital’s legal department for advice Biegler et al. 2000

  15. Futile Treatments • No common law requirement to attempt treatment, even life prolonging treatment, which is judged to be of insufficient therapeutic benefit (“clinically futile”) or overly burdensome. • You don’t have to provide futile treatments, either legally or ethically. • Indeed you are obliged NOT to provide such treatments • “… we will aim to do all we can without subjecting you to treatments and procedures that won’t work and may actually cause more harm”

  16. VIDEO • “It’s not all about the NFR”

  17. Goals of Care • Consider in categories: • Curative “beating it” • Palliative “living with disease, anticipating death” • Terminal “dying very soon” • May not (and perhaps best not) to use the term ‘NFR’ in goals of care discussions Ashby et al. 2005

  18. Goals of care • A far more useful focus of discussions than “getting the NFR” • Provides a much more comprehensive plan of care for a patient • Uses many generic communication skills, as well as those already discussed with breaking bad news and approaching anger in the clinical setting

  19. Goals of Care - Principles • What has been happening? (context) • What has been tried (and failed)? • What might be beneficial? (realistic options) • (The power of the) PAUSE • Ask for patient and/or family thoughts • What will you do? What are the limits of what you can do? (a medical recommendation) • Always provide an active management plan • Never imply ‘no care’

  20. The art (and benefits) of negotiation • Importance of negotiation, being flexible • Allows limits on things that matter most • Allows family to feel they are advocating • Allows planning for ‘next time’, aids further discussion and sets clear limits • Example: Time limited trial ABX, NIV, diuretics • “We would expect to see an improvement in 48 hours, if not, we should re assess the benefits and burdens of our present treatment plan.” • Emphasise that the current treatments are not mutually exclusive of good palliative care • NOT all or nothing

  21. Requests for Inappropriate treatments • Determine the reason behind the request • Discuss and establish clear goals of care • Avoid direct confrontation • Find common ground, a ‘window’ • “Hope for the best, plan for the worst” • “I wish we could do xxxx” • Involve others e.g. seniors within the unit, ICU • Be clear if there is no therapeutic benefit • NOT easy Clayton et al. 2007

  22. If necessary, reinforce “We know that despite what many people believe, the success of CPR and resuscitation in hospitalised patients is extremely low, even in previously healthy people. In Mary’s situation it would have almost no chance of prolonging life or reversing any of the underlying problems. In fact, it may well be a painful and even frightening experience. For that reason we would not recommend it; is that in keeping with your thoughts?”

  23. Video • Establishing goals of care

  24. But isn’t it all about choice? • 3 assumptions for ‘choice’, that • timing and outcomes are predictable • there are meaningful options available • individuals can rationally contemplate their own mortality • “… the key for patients to choose and receive end-of-life care seems to be the ability to understand that there is no choice in the matter” Drought & Koenig 2002

  25. Practice Tips & Myths • Often not really a decision • Critical that once reached, the doctor or treating team take on the responsibility • Such ‘decisions’ can be an immense burden forboth patient and family • Clear documentation is essential • Myths • Resuscitation and admission to ICU is the decision of the patient and family, we simply provide choice • We are obliged to initiate CPR in all patients suffering cardiac arrest

  26. References • Ashby MA, Kellehear A, Stoffell BF Resolving conflict in end of life care Medical Journal of Australia 2005;185(5):230-231 • Biegler P, Stewart C, Savulescu J & Skene L Determining the validity of advance directives Medical Journal of Australia 2000;172:545-548 • Clayton JM, Hancock KM, Butow PN et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregiversMedical Journal of Australia 2007;186(12):S76-108 • Diem S, Lantos, JD, Tulsky JA Cardiopulmonary resuscitation on television The New England Journal of Medicine 1996:334:1578-82 • Drought TS and Koenig BA “Choice” in end-of life decision-making: researching fact or fiction?Gerontologist 2002;42(3):114-128 • Elshove-Bolk J, Guttormsen AB & Austlid I In-hospital resuscitation of the elderly: characteristics and outcomesResuscitation 2007;74:372-376 • Faber-Langendoen K Resuscitation of patients with metastatic cancer. Is transient benefit still futileArchives of Internal Medicine 1991;151(2):235-9

  27. References • Gwinnutt C, Columb M, Harris R Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelinesResuscitation 2000;47:125-135 • Heyland DK, Frank C, Groll D, Pichora D, Dodek P, Rocker G, Gafni and for the Canadian Researchers at the End of Life Network Understanding cardiopulmonary resuscitation decision aiming: perspectives of seriously ill hospitalized patients and family membersChest 2006;130:419-428 • Hofmann JC, Wenger NS, Davis RB, Teno J, Connors AF, Desbiens N, Lynn J, Phillips RS Patient preferences for communication with physicians about end of life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment Annals of Internal Medicine 1997:127(1):1-12 • Kouwenhaven WB, Jude JR, Knickerbocker GG Closed-chest cardiac massageJAMA 1960;173:1064-7 • Miranda DR Quality of life after cardiopulmonary resuscitationChest 1994;106:524-530 • Murphy B What has happened to clinical leadership in futile care discussions?MJA 2008;188(7):418-419

  28. References • Peberdy MA, Haye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME et al. Cardiopulmonary resuscitation of adults n the hospital: A report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary ResuscitationResuscitation 2003; 58:297-308 • Peters ZR, Boyde M Improving survival after in-hospital cardiac arrest: the Australian experience American Journal of Critical Care 2007;16(3):240-246 • Saunders J Perspectives on CPR: resuscitation or resurrection?Clinical Medicine 2001;1(6):457-60 • Skrifvars MB, Castren M, Surmi J, Thoren AB, Aune S, Herlitz J Do patient characteristics or factors at resuscitation influence long-term outcome in patients survival to be discharged following in-hospital cardiac arrestJournal of Internal Medicine 2007;262:488-495 • Sonnenblick M, Friedlander Y & Steinberg A Dissociation between the wishes of terminally ill parents and decisions by their offspring Journal American Geriatric Society 1993;41(6):684-6

  29. References • Smith S, Shipton EA, Wells JE In-hospital cardiac arrest: different wards show different survival patternsAnaesthetics and Intensive Care 2007;35:522-528 • The SUPPORT Principal Investigators A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) JAMA 1995;274(20):1591-8. • Thorns AR & Ellershaw JE A survey of nursing and medical staff views on the use of cardiopulmonary resuscitation in the hospicePalliative Medicine 1999;13:225-232 • Treadway, K The CodeNEJM 2007;357(13):1273-1275 • Weil MH, Fries M In-hospital cardiac arrestCritical Care Medicine 2005;33:2825-2830

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